Healthcare Fraud - Types of Fraud Remediated Under the False Claims Act (FCA)

Types of Fraud Remediated Under the False Claims Act (FCA)

May 15, 2020

Healthcare Fraud

Healthcare fraud is rampant and it’s estimated that up to 10 cents of every dollar spent on healthcare costs is fraudulent.   This impacts the taxpayer and the insured pretty hard and if the fraud could be eliminated there could be a 10% reduction in costs which in turn benefits everyone.

So, if you have information about a healthcare provider or an individual who is defrauding the healthcare and health insurance system, there are people who want to hear about it but it must be presented in the correct way or else you may put yourself at risk and lose all the proper protections and benefits of the whistleblower laws.

Healthcare fraud at the hands of a provider may involve:

  • Billing for medical services that were never rendered
  • Providing unnecessary treatments
  • Upcoding
  • Modifying medical records
  • Filing duplicate claims
  • Changing dates and descriptions of service
  • Overprescriptions particularly with opioids
  • Kickbacks
  • Self-dealing in which a Doctor mandates you use a certain provider and has an undisclosed economic interest in that provider
  • In egregious circumstances, performing unnecessary surgery

Healthcare fraud can take many forms. These are just examples of some of the most common types of healthcare fraud. What you’ve observed and uncovered may be a different type of healthcare fraud, but fraud none-the-less, so most importantly, if you see something, say something.  A whistleblower law firm can help sort out whether the conduct is lawful or not and whether you should commence an action.

Although it may be counter-intuitive, most states do not have a whistleblower statute to advance a qui tam when private health insurance is systemically defrauded.  A few states do, like California’s whistleblower statute and Illinois’ whistleblower statute allow you to advance a claim on behalf of the private health insurance company, much like a case would proceed if it were fraud against the government.

If you’re unsure about what you’ve witnessed or discovered, and whether it constitutes fraud, ask a legal professional. If you have a feeling that something is wrong, something probably is wrong, but you don’t want to stick your neck out for reporting something if in fact the conduct was proper.  Sometimes there are straightforward violations like kickbacks, but other times the whistleblower statutes and caselaw are labyrinthine and there are exceptions to the illegality and exceptions to the exceptions so you need a capable whistleblower law firm to examine the conduct to opine on whether the circumstances make it fertile to commence a whistleblower lawsuit.